National Cancer Institute

at the National Institutes of Health

Endometrial Cancer Treatment (PDQ®)

Health Professional Version

Stage I Endometrial Cancer

Uterine serous histologies have higher rates of recurrence than do other stage I endometrioid carcinomas. The outcomes in institutional case series that utilize a policy of adjuvant carboplatin plus paclitaxel, occasionally including radiation therapy, for this histologic subtype, have been published and form the basis of management guidelines.[1-7] The Gynecologic Oncology Group (GOG-0249 [NCT00807768]) trial is comparing this chemotherapy regimen to pelvic radiation.

Standard treatment options:

A total hysterectomy and bilateral salpingo-oophorectomy should be done if the tumor:

Is well or moderately differentiated.

Involves the upper 66% of the corpus.

Has negative peritoneal cytology.

Is without vascular space invasion.

Has less than a 50% myometrial invasion.

Selected pelvic lymph nodes may be removed. If they are negative, no postoperative treatment is indicated. Postoperative treatment with a vaginal cylinder is advocated by some clinicians.[8]

For all other cases and cell types, a pelvic and selective periaortic node sampling should be combined with the total hysterectomy and bilateral salpingo-oophorectomy, if there are no medical or technical contraindications. One study found that node dissection per se did not significantly add to the overall morbidity from hysterectomy.[9] While the radiation therapy will reduce the incidence of local and regional recurrence, improved survival has not been proven and toxic effects are worse.[10-14] Results of two randomized trials on the use of adjuvant radiation therapy in patients with stage I disease did not show improved survival but did show reduced locoregional recurrence (3%–4% vs. 12%–14% after 5–6 years' median follow-up, P <.001) with an increase in side effects.[13,15,16][Level of evidence: 1iiDii] Results of a study by the Danish Endometrial Cancer Group also suggest that the absence of radiation does not improve the survival of patients with stage I, intermediate-risk disease (grade 1 and 2 with >50% myometrial invasion or grade 3 with <50% myometrial invasion).[17]

The PORTEC-2 (NCT00411138) trial randomly assigned patients with stage I endometrial cancer who did not undergo lymph node dissection to undergo vaginal brachytherapy (VBT) or external-beam radiation therapy (EBRT), with prevention of vaginal recurrence as the primary outcome.[18] At 5 years, there was no difference in the rates of vaginal recurrence, locoregional recurrence, progression-free survival or overall survival (OS) (84.8% [95% confidence interval (CI), 79.3–90.3] vs. 79.6% [95% CI, 71.2–88.0] for VBT and EBRT, respectively; P = .57). There were significantly fewer gastrointestinal toxic effects and significantly improved quality of life in the VBT group, making VBT the preferred option for adjuvant treatment of patients with stage I disease.[18,19][Level of evidence: 1iA]

Patients who have medical contraindications to surgery may be treated with radiation therapy alone, but inferior cure rates below those attained with surgery may occur.[8,20,21]

Several randomized trials have compared total laparoscopic hysterectomy (TLH) with the standard open procedure, total abdominal hysterectomy (TAH), for patients with early-stage endometrial cancer. Feasibility of the laparoscopic approach has been confirmed, although TLH is associated with a longer operative time.[22-24] TLH had an improved [22,23] or similar [24] adverse event profile and a shorter hospital stay [22-24] when compared with TAH. TLH was associated with less pain and quicker resumption of daily activities,[24,25] although one study found that most of the gains in quality of life favoring laparoscopy at the 6-week postsurgical period were no longer significant at 6 months.[24,25]

The completed GOG-Lamina-associated polypeptide 2 (GOG-LAP2) trial included 2,616 patients with clinical stage I to IIA disease and randomly assigned them two-to-one to comprehensive surgical staging via laparoscopy or laparotomy.[26] Time to recurrence was the primary endpoint, with noninferiority defined as a difference in recurrence rate of less than 5.3% between the two groups at 3 years. The recurrence rate at 3 years was 10.24% for patients in the laparotomy arm, compared with 11.39% for patients in the laparoscopy arm, with an estimated difference between groups of 1.14% (90% lower bound, -1.278; 95% upper bound, 3.996). Although this difference was lower than the prespecified limit, the statistical requirements for noninferiority were not met because of a lower-than-expected number of recurrences in both groups. A Cochrane Review of the use of laparoscopic staging included four randomized controlled trials that reported OS and PFS, although 90% of the patients were from the GOG-LAP2 trial. Overall, laparoscopy was associated with similar OS and PFS rates when it was compared with laparotomy.[27][Level of evidence: 1iiA]The OS at 5 years was 89.8% in both groups. Future analyses may determine whether there are subgroups of patients for whom there is a clinically significant decrement when laparoscopic staging is utilized.[26][Level of evidence: 1iiDiii]

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I endometrial carcinoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.